Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Monday, March 05, 2007

Burnout: Fanning the Flames

In trying to understand my own burnout, "control" (or lack thereof) is a dominant theme. This is nothing new. In fact, I doubt I'm unearthing bones not already thoroughly analyzed. But I can give instructive personal examples.

For a while I was on the board of directors of my clinic, which was then and is even more so now one of the most successful doctor-owned and -managed in the US. During my tenure, we were deeply in the thrall of the managed care model as the guarantor of our future. My feelings about it were, diplomatically, mixed. If I may be allowed to say it for the ten thousandth time, providing cost-effective care has always been as much a part of me as the Krebs Cycle. I've never needed anyone to remind me of it. Nor -- take my word for it -- have I ever been a trigger-happy surgeon: many is the patient sent to me for an operation, returned to his/her referring doc with a note pinned to the shirt saying "Please excuse Johhny from surgery today. He doesn't need it." So the idea of being required to seek approval from a peach-fuzzed (or even a grey-muzzled) primary care doc (need I repeat myself?) sat, diplomatically, unsteadily in my saddle. (In fairness, some of the internists who knew me over several years filled out all the authorizations the minute they sent the patient to me. Not, however, the family docs. But I've been over that. In one sense of "over" anyway.) Frosting a burnt cake, we even agreed to pay primary care docs a "gatekeeper" fee. Perfect.

I never objected to scrutiny; in fact, I welcomed any legitimate comparisons of my work to that of others. But it was always my contention that being in a clinic was the ideal situation in which paperwork could be minimized. After all, we had a medical director whose job included oversight; we knew each other well; we worked in a closed shop. Hell, we'd even cashiered a couple of losers. Ought there not be a presumption of quality? So when one of my fellow board members -- a young family doc whom I actually admired for his practicality -- announced at one of our meetings that he'd come up with his own form (in addition to the required ones!) he was going to send to specialists along with his patients, and showed it to us (couple of pages, lots of blanks to fill in) I hit the roof. Sailed right through it. Covered the man, the board room, and myself with plaster. Lots of it. Then, still rising, I resigned from the board. The form was never distributed, but it took enough days for my pulse to return to its usual 1.5X that I figured who needs the extra aggravation.

Every few weeks the medical staff at the hospital came up with a new committee, for which it obtained members by also coming up with regulations requiring and penalties for failing to sign on. Among the three or four on which I sat was the "Blood Utilization Committee." People from the blood bank (really good people, I might add) presented quarterly data on the use of blood and blood products and we looked into any deviations from accepted indications. Without fail, the data showed near perfect compliance, with the only outliers being nephrologists buffing up their dialysis patients -- outside of "standard" indications, but within "special" protocols. If ever there were proof that doctors knew what they were doing in an area, this was it. Yet, after a couple of years on the committee we were presented, for our approval, with a blood products ordering form. What's the patient's blood count, list this lab or that, provide seven indications for the use of the product you are ordering and click your heels three times. And yeah, another roof repair job was needed. I'm happy to say the form didn't appear in charts until a year or two after I was off the committee. But appear it did.

Small potatoes, I suppose. But multiply those incidents by a number that increased every year, and pretty soon there's salmonella in the salad. It'd be easy to quantify the amount of paperwork, if I had the desire and the money to hire a hundred people to work on it. What's hard is to measure the additive effect on the psyche; especially a steadily smoldering one. If it were one or two things, I might not have ex/imploded. Had I been getting more sleep, spending more time away from the hospital, maybe some of it would have rolled off. But at every turn, literally almost weekly by the latter years of my career, I'd find myself staring numbly at another missive announcing another rule, another form, another penalty, from the clinic board, the hospital administration, from medicare, blue cross et al, the malpractice insurer. Not so numbly; more accurately, with cold and trembling hands. Seriously. If adrenaline were water, I think my adrenals could have pumped out New Orleans.

I'm a lot of bad things, but stupid isn't one of them. And I'm enough of a realist to recognize it ain't Camelot and doctors -- myself included -- aren't perfect. (Some much less so than others.) So yes I accept that scrutiny is necessary, regulations are unavoidable. "The best of all possible worlds" is as illusory an idea as is that of a functioning Congress. But somewhere along the line -- and it happened in my practice lifetime -- the assumption changed from "doctors generally know what they're doing" to "doctors are incompetent, uncaring, unethical, and untrustworthy." Officially, anyway. Paperwork-wise. I may be more paranoid than most: I guess I took every form as a personal accusation, and it grated more deeply in me than in some of my peers. But I know it affects everyone.

I don't think it's just ego, or some inflated sense of myself. To a degree it's the opposite: I beat myself bloody over the slightest deviation from what I considered perfection, and generally knocked myself out to make amends and to prevent the next blemish. Yet I foolishly imagined that I had more control over my world than was true: why, I thought, can't problems just get ironed out? Do we really need all these committees breathing down out necks, these forms, these threats? Can't we just talk when someone thinks there's a problem? (Answer: of course not!)

Here's another example of how it works: a lot of surgeons use fluoroscopy during surgery. We don't operate the machines, but we are quite capable of interpreting what we're seeing, because, among other things, we know exactly what we're looking for when we're doing it. [Disclosure: there may be some politics at work here. Before useful intra-operative fluoro, the patient would be on a special table under which an Xray plate was slud, a hard film taken, and the radiologist would read it -- with or without the film getting returned to the OR for viewing by the surgeon. I always insisted on getting the film brought back before the radiologist saw it and generally we were sewing up by the time I got the call. With fluoro, I rarely had a hard copy made, so the radiologist never saw a film and, therefore, never got to bill for (irrelevant) reading. So the advent of surgeons reading their own fluoros was not well-received in all quarters.] Nonetheless, once upon a time I and many other surgeons were using it with no problems. Then one day a new cardiologist came to town, and used fluoro in the Xray department for some procedure or another, and someone turned him in for exposing the patient to too much radiation. OK, fair enough. But what was the response? Talk to him? Maybe even send around a little memo with information about proper use? Hell no. With no input from any non-radiologist doc who used fluoroscopy, the medical staff officers got together and made some rules. Mind you, the incident occurred not in the OR, but in the radiology suite; but suddenly everyone who used fluoro was required to take a course, get certified, fill out paperwork for each case, or have a radiologist present. For one friggin' incident, by a non-surgeon, after a gazillion proper uses!!! Here, in exact real-time replication, is how much time my Xrays took (for any radiologists out there, the image was saved until I sauntered over for a closer look): "OK, ready? Shoot. Thank you."

8 comments:

Sid, once again, you've given me more ripe material for my third book. I've long felt that practicing medicine had evolved into a game where the fools are threatening to take over. This is a literary enema just itching to get between my pages.

Sid, what we're seeing is a massive "regression to the mean" in medicine. The process you're describing gets rid of a few dangerous docs but on the other side many of the excellent docs burn out and quit over the bureaucratic overreaction. What we're left with is safe mediocraty.

There should always be a striving for quality and excellence in patient care. It is just a shame when superfluous, bureaucratic policies hinder the process. Why don't these decision makers actually call a meeting with the people that do the work,gather info and THEN create new policy if necessary? How it looks on paper often plays out differently in real life experience. Being in the trench is a totally different experience than walking above and around it. I have seen this and heard the complaints and experienced it myself while working in the hospital. It happens at all levels.

Again, always good to make improvements - just need to meet with the people that will be affected by the changes. If they did this in the 1st place they might save time, money and energy down the road.

Better communication is key! Then sometimes - decisions just have to be made, but if wrong then there needs to be flexibility for improvement.

Data collection as a discrete task rather than as a natural part of the workflow - the bane of my existence.

It's not just medicine - everybody has gotten form-happy, since it's become so easy to generate and distribute paper forms, and the prevailing wisdom is to collect the data whether it's immediately useful or not. Worse yet, people are computerizing bad process left, right and sideways, which leads them to expensive, poorly-conceived electronic processes.

Given that I love an engineering solution to a societal problem, I look at the fluoroscopy incident as a failure of technology to inform smart users (always assume users are smart when building sophisticated equipment intended for use by people who do complicated things for a living) that they are about to do a dumb thing. It seems possible to engineer the device in such a way that if a user is getting close to a safety threshold, a subtle yet firm reminder is offered. Smart person clues in, adjusts things, tragedy is averted.

Note that my assumption is that these users are *smart* - not *infallible*; people make mistakes, get focussed on the one thing (performing the procedure) to the neglect of the other (monitoring total exposure). Pilots have done the same things (dealt with the oil indicator lamp while the plane flies into the Everglades), accountants count the paper clips while the exposures via derivatives skyrocket....need I go on?)

The problem is, less-smart people are assigned to fix these problems, and they inevitably do it by inserting steps in the smart-people work process that, on the surface, seek to prevent future incidents, but is seen as intrusive to the work of smart people by the smart people. Smart people being smart people either call on their power and position in the organization to block the actions of non-smart people, or sit there and take it with varying degrees of resentment and attempts to engineer past the blockades.

The solution is to have smart people helping smart people, who are sensitive to the delicate, individualized nature of smart-people work. The blood services piece is a good example. All the data to support or deny the blood work was probably already extant - I'm assuming nobody had to order more lab work or examine the patient more extensively or do anything more than fill out the form to have all the data points, and it's lame to make smart people do that when there could be any number of other ways to deduce or infer the same.

When the data collection or safety verification or UR or whatever else doesn't insult the intelligence or waste the time of smart people, it's generally acceptable to them - sometimes, it's even welcomed. The problem isn't trying to be systematic about things; it's having ham-handed non-smart people with good intentions implementing half-baked "solutions".

eric: it's also about the rapid descent into corporate-think. In the case of the Xray, I'm certain there was a time when the medical staff officers would have, in their own practice, addressed the issue differently. But once on a board, you start to think like communal idiots. Also, the machines generally do start to beep or act in various ways when a level of use is approached. I can't recall the specifics: I'm sure there were warnings, both from the machine and the tech. And it's (most likely) not as if the doc just bulled ahead: if he had a certain thing that needed to be accomplished, and if there were difficulties making it take longer than expected, he likely had no choice (needing to use Xray to get the job done) but to push past the warning dose. Which, by the way, is probably well below an actual danger point. Also, note that the issue, if any, would be the doc's competence in the procedure, not in the use of Xray. So the issued rules were at least doubly stupid, making the practice environment even more depressing.

People sometimes get too fixated on the paperwork/proper procedure. Last month I was in the OR with a ruptured AAA that was brought into the OR with a 3rd year med student straddling the bed doing chest compressions. We got him back in time to start the surgery, but for the better part of the first hour I had a hell of a time keeping his pressure up. We were transfusing like mad (23 units in all by the time we were done) and the blood bank kept calling up asking for a sample. The pt went down in the ED before his workup was finished, so we had been giving uncrossmatched. Once he had somewhat stablilized, I started an art line and drew off the sample for the type and cross. I almost died when the circulator told the blood bank (when they called asking what took so long to get the sample) "It's hard to get a blood sample when there's no blood pressure" and hung up the phone.

I thought I'd suggest an alternate explanation to what you're describing, which I have in my own practice referred to as the "stupefication of medicine.". I, too, have sat on the very same Blood Utilization Committee, listening to suggestions on writing decision trees for transfusion. You and I, who transfuse blood to replace what we can see spilling out over the sides of an open abdomen, don't need a form with an algorithm to help understand when to transfuse. Sadly, the vast majority of our successors do. Trained in an eighty hour world, they are, I believe, accustomed to always having guidelines, preprinted order sets, and online med searches for standard of care. Every aspect of patient care is spelled out, and every possibility has it's own special cubicle, it's own code. The average Joe doesn't have independent thought - it's just too hard.

The reason the system discourages independent thought and builds methods to support the cattle that stay between the lines is, simply, money. It takes oh, so long, to train a person to understand how something works, it's vagaries and limitations. Take for example a sphygmomanometer. Once upon a time nurses took blood pressures. That is a trained individual who has many responsibilities in patient care, and taking vitals takes up time. But lo, a hospital can hire someone with a third grade education for much, much less to use an automated BP machine and record the numbers, freeing up trained professionals for other work. Or sometimes, I suspect, it evolved the other way around. Perhaps there were not enough trained professionals to do the work, or not enough money to pay trained professionals to do the work, and so hospitals resort to alternate, cheaper more readily available solutions.

Of course, it does mean that when a crazy number comes out of the vitals machine, the aide with the third grade education dutifully writes down that the patient has a temperature of 43, for example. Or worse, the patient on observation for a small pneumothorax has a sat of 80... Dutifully recorded at tremendous cost savings. See? All about money.

And in the case of getting an inexpensive tech to do vitals, I wonder how much of a savings it is. So much physical assessment and teaching and caring can go on during routine vitals. And problems can be caught by someone who knows what those numbers and the rest of what's going on means!

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.